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Clinical Documentation Specialist II
1 month ago
Are you a skilled nursing professional looking for a challenging role that utilizes your clinical expertise?
We are seeking a Clinical Documentation Specialist II to join our team at Orlando Health. As a key member of our clinical documentation excellence program, you will play a critical role in ensuring the accuracy and completeness of patient medical records.
About the Job
In this role, you will conduct concurrent reviews of patient medical records, identifying areas where documentation may be lacking or unclear. You will work closely with coding, HIM, and UR departments to ensure that medical records accurately reflect the acuity of patients and the level of care provided.
You will also be responsible for reviewing medical records concurrently for documentation not yet present but supported by clinical indicators. This will involve performing thorough chart reviews to identify co-morbidities and complications, and documenting these findings within the concurrent CDS worksheet.
Key Responsibilities
This is a challenging and rewarding role that requires strong clinical knowledge, excellent communication skills, and the ability to work independently in a time-oriented environment. Key responsibilities include:
• Conducting initial and follow-up concurrent reviews across all hospitals on targeted admissions for opportunities to clarify documentation in the medical record
• Coordinating with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided
• Reviewing medical records concurrently for documentation not yet in the record but supported by clinical indicators
• Identifying co-morbidities/complications and documenting these appropriately within the concurrent CDS worksheet
• Determining the appropriate principal diagnosis of the patient
• Demonstrating an understanding of the importance of capturing all appropriate secondary diagnoses for quality purposes
Requirements
To be successful in this role, you must have three years of acute care hospital nursing experience and a valid RN license in the State of Florida or a multistate RN license. You should possess extensive clinical knowledge and understanding of pathology/physiology, as well as excellent written and verbal communication skills.
Salary and Benefits
The estimated salary for this role is $75,000-$90,000 per year, depending on experience. Orlando Health offers a comprehensive benefits package, including competitive pay, evening, night, and weekend shift differentials, student loan repayment, tuition reimbursement, free college education programs, retirement savings, paid paternity leave, fertility benefits, backup elder and childcare, pet insurance, PTO/holidays, and more for full-time and part-time employees.
Join Our Team
At Orlando Health, we value our employees and strive to provide a positive and supportive work environment. If you are a motivated and detail-oriented nursing professional looking for a new challenge, please apply for this exciting opportunity.
